Maine dental therapist bill heats up, but impact may be minimal

While dentists and dental hygienists clash over a bill pending in the Legislature that would create a new licensed dental health profession – the “mid-level dental therapist” – the practical effect if it passes might be minimal, based on one state’s experience.

Dentists are lobbying to defeat the measure. Final votes are expected this week, and if approved, the bill could soon land on Gov. Paul LePage’s desk.

Additional Photos

Scarborough dentist Demi Kouzounas and her dental assistant, Sue Cote, work with a patient. Dr. Kouzounas is opposed to efforts in the state Legislature to establish a dental therapy position in the state. John Ewing/Staff Photographer

Dental therapists would be able to perform more dental procedures than hygienists can – filling cavities, for example – but would not receive as much training as dentists do. Because of the extra training, dental therapists would receive higher salaries than hygienists typically do.

The idea behind creating the therapist position is that they would be able to work in dental practices in rural areas where, advocates say, dental care is not readily available to some residents.

Maine’s legislation is modeled after Minnesota’s, one of only two states that allow dental therapists to practice, and supporters have brought in experts from that state to testify on behalf of the bill.

But in Minnesota, only 29 therapists have become licensed since the law started allowing colleges to graduate dental therapists from a two-year program in 2009. The law has not increased access to dental care in rural towns, according to the Minnesota Dental Association, which represents dentists in that state.

Dr. Michael Flynn, past president of the association, said most of the licensed therapists in Minnesota have found work in urban areas. Part of the reason for the lack of demand elsewhere is that dentists working in low-income, rural areas cannot afford additional, higher-paid staff, he said.

There are 4,000 dentists and more than 10,000 hygienists and dental assistants in Minnesota, the association says.

“Statistically, (dental therapists) represent 0.2 percent of our workforce,” said Flynn. With only two dozen graduates per year, there is no indication that demand for the program is likely to increase, he said.

The reason may lie with how the law is structured in Minnesota, and proposed in Maine.

Under the Maine bill, while a dental therapist could theoretically open his or her own private practice, candidates would need written permission from a Maine dentist to set up shop and would have to work under the “general supervision” of a dentist.

While “general supervision” would not require dentists to look over a therapist’s shoulder or even be in the same building, therapists would have to have their supervising dentists check their work, by examining X-rays, for example.

Rep. Heather Sirocki, R-Scarborough, said dentists would be unlikely to sign such an agreement if it would create additional competition for them.

“The bill is really designed for the therapists to work for a dentist,” said Sirocki, a dental hygienist and co-sponsor of the bill. “It’s intended for them to be part of a team. It’s not adversarial.”

Sirocki said it’s similar to how a nurse-practitioner or physician assistant could work out of a doctor’s office. Sirocki said the bill should not be perceived as a threat to dentists because it gives dentists control over the marketplace.

“There’s a lot of fear surrounding this bill. The fear is not what this bill does today, but what might happen (in the future),” Sirocki said. Opponents fear that if the bill passes, some of the restrictions on dental therapists might be eased later, she said.

But Sirocki said in rural areas, there will be greater demand for dental therapists. She said some dentists in northern Maine are in their 80s and still practicing because closing would leave residents with nowhere to go for dental care.

She said those elderly dentists would be more likely to welcome a dental therapist, because it would allow the dentists to reduce their hours, with therapists taking up the bulk of the routine work.

“If you go into the outer reaches of Maine, there is a problem with access,” Sirocki said. The bill would also increase access to dental care in nursing homes and schools, proponents say.

But the Maine Dental Association disputes that there’s an access problem – 97 percent of the state is within 15 miles of a dentist, the association contends.

Dr. Jonathan Shenkin, an Augusta pediatric dentist, said the number of practicing dentists has increased from 604 in 2006 to 677 in 2013.

Shenkin said a number of them have been younger dentists who have opened practices in rural Maine. The state has the second-lowest rate of untreated tooth decay among third-graders in the nation, Shenkin said.

“Why are we calling this a crisis in Maine?” Shenkin said. “Maine does an excellent job of getting people the treatment they need.”

He said the most pressing issues in Maine are economic and preventative. Low reimbursement rates for Medicaid – known as MaineCare in Maine – make it more financially difficult for dentists to accept many Medicaid patients, he said. Also, while children on MaineCare are covered for dental care, adult MaineCare patients are not. So adult MaineCare recipients have to pay for dental care out-of-pocket, and many can’t afford to do so, Shenkin said.

Scarborough dentist Dr. Demi Kouzounas said that the bill is a “rush job” and that Maine should see how many dentists graduate from a new dental school at the University of New England before declaring there is a dentist shortage.

“They’re pushing an out-of-state model onto us and I’m not sure why,” she said. “There is no access problem.”

Dr. Michael Dowling, a Falmouth pediatric dentist, said the most serious problem for access is not the number of dentists or where they’re located, but getting residents to go to the dentist. Another bill before the Legislature would create a dental coordinator position in Maine, with the goal of identifying children on MaineCare who have not been to the dentist in the past year and prodding them to go to the dentist. Dowling said many parents may not know that dental care is free for their children on MaineCare.

Sirocki said she has heard senators were “intensely” lobbied over the weekend. In initial votes, the bill passed the House 102-39, but the Senate vote was closer – 19-16 in favor. Adrienne Bennett, spokeswoman for Gov. Paul LePage, wrote in an email response that the governor has not yet taken a public position.

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